Delusions of jealousy

In the symptom complex of disorders of the thought process, delirium occupies a special place - an erroneous belief, reasoning, conclusions, interconnected with a person's very personal concerns, in which it is impossible to convince him otherwise by any arguments.

One of the manifestations of delirium is delusional jealousy or Othello syndrome. Jealousy is a natural emotion, a manifestation of a feeling of resentment towards a more successful rival. Normally, a person is jealous only when there is strong evidence, he is ready to perceive new information, in light of which he can change his opinion. Usually one rival is assumed.

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Epidemiology

Geographical intrazonality and ethnic specifics of delusional jealousy have not been studied, although observations of such patients are systematized, scientific articles devoted to this topic are published in European, North American publications, as well as in the Australian region. There is an opinion that in societies where proprietary positions in relation to a partner do not matter, delusional jealousy appears less often.

Practicing psychiatrists often encounter pathological jealousy in various mental pathologies, although it can be assumed that in most such cases people do not seek psychiatric help.

The results of the analysis of a sample of episodes of delusional jealousy conducted in the USA, in individuals receiving psychiatric care, show that out of 20 patients there was only one woman, most of them (80%) were family people. The average age of the onset of mental disorders was 28 years, manifestations of delusional jealousy were noted approximately ten years later. The oldest patient was 77 years old. No correspondence was found between belonging to a certain ethnic group and the development of delusional jealousy.

Gender aspects of delusional jealousy

As a rule, delusional jealousy begins in men after 40 years of age, and affects people with a history of mental disorders, drunkenness, and sexual dysfunction. If delusional jealousy develops rapidly against the background of mental illness, then with alcoholism it develops gradually. At first, the patient is jealous when drunk, and this is perceived as ordinary abuse. Then the patient expresses suspicions of infidelity not only when drunk, but also when sober. Often there is an imaginary rival, often a well-known person. The man checks every step of his wife, making illogical conclusions. Living with him becomes difficult and dangerous, aggression increases, he often raises his hand to his wife, and occasionally to his rival.

Among women, cases of delusional jealousy are observed much less frequently. Usually, these are women who drink. The consequences of female delusional jealousy are no less dangerous. Feelings acquire a pathological emotional coloring that does not correspond to reality. Jealousy accompanies a woman everywhere, makes her quarrel, causes insomnia and depression

Delusional jealousy in women is accompanied by paroxysmal aggression, followed by a depressive state. With delusional jealousy, the level of serotonin (the hormone of happiness) drops sharply. To cover its deficiency, a woman is predisposed to have a good row, which contributes to an increase in the level of dopamine (the hormone of pleasure).

In contrast to men who simply raise their hands, among women's affective acts it is necessary to single out the thirst for revenge, since revenge activates the production of dopamine. The feeling of pleasure from revenge becomes habitual and leads to sophisticated and cruel vindictiveness.

Causes delusions of jealousy

Modern psychiatry does not know the exact answer to the question about the causes of delusional jealousy. There are several theories of the pathogenesis of Othello syndrome, each of which has a right to exist.

The significance of various factors that trigger the mechanism of pathological jealousy is still under study.

It is safe to say that heredity plays a significant role in this. As with other mental disorders, delusional jealousy is often observed in people whose older relatives also had this pathology to a greater or lesser degree.

The influence of pathological processes in different parts of the brain on the appearance of symptoms of delirium is also studied. Deficiency of any neurotransmitter (a mediator transmitting signals between neurons of the brain), which arose due to a congenital or acquired mental illness, causes a disruption of the mechanisms of normal brain function and triggers unnatural processes: depression, aggression, delusional disorders.

The impetus for the development of pathological jealousy can be given by stress, alcohol abuse, drugs. Poor vision, hearing, disability, tendencies to isolation also become factors contributing to the emergence of delusional disorders.

Delusion is a common symptom of a number of mental illnesses, but it is not their initial stage, since delusional jealousy develops later than, for example, schizophrenia.

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Risk factors

Risk factors that may contribute to patients committing socially dangerous actions during periods of delusional jealousy are considered to be: pre-morbid epileptoid characteristics of the jealous person's behavior; the presence of hallucinations and/or paranoid personality disorders, dysphoric affect, difficulties in communicating with members of the opposite sex, provocative behavior of a sexual partner, psychological incompatibility with a partner, financial difficulties in the family, the appearance of "insight" regarding the partner's connection with a specific person, the presence of sadistic tendencies, surveillance of a partner, investigations, inspections, searches.

People suffering from delusional jealousy often resort to violence to obtain confirmation that they are right.

The partner who is accused of cheating is guilty until proven otherwise, but it is impossible to refute the accusations, because rational arguments cannot convince a madman.

Violence is often characteristic of relationships accompanied by jealousy, however, with delusional jealousy the danger increases many times over. Both denial of the fact of betrayal and false confessions of a partner tired of endless suspicions can irritate the jealous person and push him to violence.

Victims of jealousy killers are usually sexual partners, current and former. This is typical for the vast majority of criminal acts committed by both men and women. Much less often are charges brought or violence committed against people identified as rivals.

Males with Othello syndrome more often than females suffering from this pathology direct aggression towards their other half, and the injuries inflicted are characterized by greater severity.

Cases of illegal actions are often associated with paranoid delusions with hallucinations commanding the punishment of the culprit. Abuse of psychotropic substances (alcohol and drugs) increases the possibility of committing violence. All this confirms that individuals with delusions of jealousy commit crimes, often under the influence of additional psychotic symptoms.

It is impossible to accurately assess the degree of difference in the nature of violent actions depending on the causes of delusional jealousy, since physical violence committed in the family is most often hidden, and both spouses - both the offender and the victim. The same can be said about which of the ideas of jealousy (delusional, obsessive or overvalued) increases the likelihood of committing violence. However, the psychotic variety of delusional jealousy, which is characteristic of all psychoses, more often accompanies the use of force. In general, delusional clouding of the mind has a high degree of probability of committing violence.

Children whose father (and much less often their mother) is morbidly jealous suffer emotionally and often physically. They are unwitting participants in frequent conflicts between their parents, and can be injured accidentally, and sometimes intentionally, since patients often develop the conviction that they are raising a rival's child.

Children can be drawn into detective activities, such as spying on a "guilty" parent. They often become witnesses to crimes or suicides.

Partners of pathological jealous people are prone to mental disorders, they are accompanied by a state of constant anxiety. They often begin to abuse antidepressants, alcohol, drugs, and sometimes they themselves can resort to violence, unable to withstand the constant pressure from the patient.

Factors that reduce the risk of socially dangerous actions of the patient can be considered to be the monotonous content of delusional jealousy, not acquiring new details, a depressive state, the absence of a candidate for the role of a lover and investigative activity.

However, the depression of a jealous person carries the threat of suicide, since previous acts of violence against a partner can lead to deep remorse.

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Pathogenesis

Theories of the pathogenesis of delusional jealousy, based on psychoanalysis, with Freud's light hand, consider its cause to be self-defense against latent homosexuality. A paranoid man is jealous of his wife for the person who caused him unconscious sexual attraction. This hypothesis is not supported by clinical studies, since the overwhelming majority of patients with this symptom do not show inclinations toward same-sex love, and most homosexuals do not suffer from paranoia or delusional disorders.

Bowlby and his attachment theory explain the emergence of jealousy in an individual as uncertainty about his partner's attachment to him. As a rule, delusions of jealousy affect people with an insecure attachment prototype (for example, those separated from their parents for a long time in childhood).

There is a theory that a person is predisposed to the development of pathological jealousy by a feeling of personal inadequacy and lack of security, hypersensitivity. People with such characteristics often perceive and interpret information distortedly, any event can cause an incorrect guess and trigger the mechanism of delusional jealousy. This theory is conceptually similar to the attachment theory.

Certainly, a significant role in the development of Othello syndrome is played by a decrease in male potency, as well as real or imagined anatomical defects of the genitals. However, not all psychiatrists are inclined to consider sexual dysfunction as the primary cause of pathological jealousy.

The importance of family and social factors should not be underestimated. In societies where a man occupies a dominant position and a woman is subordinate, any manifestation of her independence can be perceived as infidelity. Jealousy in this case justifies violence against the unfaithful woman.

Some paranoid patients, as clinical observations show, cannot form trusting relationships even with a loved one. Probably, the lack of trust is caused by consistently unfriendly relationships in the parental family, where total control on the part of the mother and distance or sadistic attitudes on the part of the father were often noted.

Often, delusional jealousy is provoked by hormonal dysfunctions, cerebral vascular pathologies, and chronic alcoholism. This disorder is usually found among men who abuse alcohol for a long time, who consequently have sexual, psychological, and social problems and feel their inadequacy. The situation worsens gradually: at first, delusional jealousy occurs only when drunk, then cases of accusations of infidelity become more frequent, and later, coexistence turns into a continuous scandal. The man constantly controls his partner, suspects everyone around him of having an affair with her. Living with him becomes unsafe.

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Symptoms delusions of jealousy

In the case of pathological jealousy, the individual's speculations and fantasies often have no real evidence, he does not back down from his ideas even in the face of convincing arguments to the contrary and often accuses himself of cheating on several rivals. Delusional jealousy is characterized by confidence formed from fantasies rather than facts, as well as a lack of logic.

In fact, morbid jealousy is one of the symptoms of various mental illnesses. For example, schizophrenia. In this case, the so-called Othello syndrome usually manifests itself by the age of 40, accompanied by aggressive manifestations in men and depressive ones in women.

The presence of delusional jealousy can be assumed by the presence of groundless accusations of infidelity and their categorical nature, the patient’s complete conviction that he is right, an illogical interpretation of any actions of the other half (any actions are seen as a desire to deceive and cheat), talkativeness, expansiveness, and failure to perceive his pathology.

The plot of this pathology is a strong concern about the imaginary betrayal of a sexual partner. Typical forms of symptoms of this mental pathology are delusional, obsessive and overvalued ideas.

There is an opinion that delusional jealousy is a variation of delusional disorder, therefore, the name "delusional jealousy" does not correspond to the truth. The key mental pathology in this case is delusional infidelity of the partner, which is often combined with the patient's guesses that the guilty party is trying to poison him (her); slips drugs that reduce sexual activity; puts the patient to sleep and at this time has sex with a rival. These delusional ideas are related to delusional persecution, and delusional jealousy is its variety.

Delusional ideas of infidelity can be initial symptoms of schizophrenia or additional signs of an existing mental illness. These are the individual's own conjectures, unacceptable to others, but not causing inconvenience to him. The patient himself considers them to be the truth, he does not resist these thoughts.

Delusional jealousy is considered a modification of delusional disorder in the classifier of the American Psychiatric Association (fourth reprint) and the International Classification of Diseases (tenth reprint), which is used today by domestic doctors.

It happens that delusional ideas of infidelity do not appear against the background of other mental illnesses and exist on their own. Their content is distinguished by logic, consistency and plausibility, unlike the strange associations inherent in schizophrenic delirium.

Mental function disorders characterized by delusional jealousy include emotional state disorders (clinical depression, manic-depressive psychosis), and in general, it can occur with any disorders of brain function.

In the case of obsessive jealousy, thoughts about the partner's betrayal take up almost all of the time, it is impossible for the patient not to think about it, the relationship with the partner begins to deteriorate, his freedom is limited, and his actions are controlled.

In this case, thoughts about betrayal are something abstract in the patient's perception, but he is unable to get rid of them. Such patients realize that their fears are groundless, and they sometimes feel ashamed. They are constantly in a stressful state caused by obsessive ideas that contradict the real situation. As a result, a continuous process of transition from obsessive pathological jealousy to delusional jealousy may begin.

At the end of the last century, it was suggested that Othello syndrome may manifest itself as an overvalued idea, namely, a completely acceptable, understandable belief on which the patient is focused to an inadequate degree. It does not cause internal protest in the patient, and although it is not considered delusional, the patient checks the actions of the partner, trying to make sure that there is no betrayal. How widespread this form of pathology is is unknown, since it is assumed that patients with overvalued ideas are usually outside the scope of attention of psychiatry. It is considered possible that overvalued ideas are delusions of jealousy.

People with borderline emotional disorders, especially paranoid ones, are predisposed to any manifestations of delusional jealousy.

They are characterized by a negative and not fully formed self-identification, a feeling of low self-worth, anxiety about possible refusal in intimate relationships, betrayal of a partner, affective instability, and the projection of unacceptable desires onto a partner.

In delusional jealousy, combined disorders are common; in its pure form, it is very rare. The presence of various combinations (with personality disorders, mental pathologies, alcohol and drug abuse) usually creates a very complex and ambiguous clinical picture of the disease.

The first signs of the development of delusional jealousy are gloomy thoughtfulness with frequently repeated obsessive conversations about infidelity, at first these are rare episodes. Then they become more frequent, specific and categorical accusations begin, often devoid of elementary logic, and the failure to accept any justifying arguments. The patient is not aware of his pathology.

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Dynamics of delusional jealousy

Delusional ideas of jealousy that appear in schizophrenics are classified as intellectual delirium. They have significant differences from similar ideas in sensory delirium in epileptics, alcoholics or in patients with cerebral atherosclerosis with mental disorders.

The dynamics of alcoholic delusional jealousy is characterized by a gradual increase in symptoms. Initially, patients express their doubts or accuse of cheating episodically, in a drunken state or against the background of withdrawal syndrome. After some time, the delusional interpretation of previously occurring cases appears even in a sober state. At the onset of the disease, a role is played by a real change for the worse in family relations, caused by the patient's long-term drunkenness.

Since the content of the delusion is based on the current state of affairs in the family, the jealous person's statements seem very plausible to those around him. Then the interpretation of events becomes less realistic, filling with a mass of invented details. The plot of the delusion of jealousy can expand, enriched with new details. The patient begins to show aggression and becomes dangerous.

The dynamics of delusional jealousy in individuals with schizophrenia spectrum disorders is observed in two variants of continuous flow - with increasing symptoms and with an upcoming replacement of the plot of delusion, and in two variants of paroxysmal flow - without increasing symptoms and with their increasing. Malignancy of the process can also be observed - increasing symptoms and transition from paroxysmal flow to continuous.

The aggravation of the process of pathological jealousy in individuals with schizophrenia spectrum disorders occurs according to the following pattern: paranoid delusions of jealousy gradually acquire paranoid features → the appearance of delusional elements of a different content → the addition of hallucinations → the emergence of paraphrenic components of delusional jealousy.

Paranoid delusions of jealousy in people with schizophrenia-type disorders are mostly formed as a sudden insight, occasionally there is a gradual understanding based on overvalued ideas of jealousy. At first, the patients' reasoning does not give the impression of being morbid. But their mood is depressed, with elements of irritability and even malice.

Paranoid delusions of jealousy are characterized by illogicality, absurdity, and often absurdity. Other themes are connected to the theme of jealousy, and it is accompanied by hallucinations. Depressive-affective elements dominate the mood, and the behavioral line does not coincide with delirious worries.

Paraphrenia is the apotheosis of chronic delusional psychoses. This stage is characterized by a combined mania of grandeur, persecution and influence, a change in affect, automatism appears in reasoning, actions and movements. The plot of delirium is enriched with variations, acquires new details, expands. In this state, patients do not even try to substantiate their conjectures, they seem like axioms to madmen. Paraphrenia is characterized by imaginary memories, real events in which are mixed with fantastic ones. Usually, patients are in a state of euphoria: from more restrained to frankly manic.

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Stages

The development of delusional disorder occurs gradually; even the closest people may not notice its onset.

It all starts with a delirious mood, when the patient has a premonition of some negative changes, an anxious state about the trouble that threatens him or his well-being.

These thoughts are persistently present, the feeling of anxiety increases and a delusional perception of past and current events appears, a delusional explanation of individual facts begins to form, an accused appears. For example, in the case of delusional jealousy, a husband who abuses alcohol will explain conflicts in the family not by his drunkenness, but by the appearance of a lover of the unfaithful wife. This idea occupies the patient more and more and a delusional interpretation of all the events that occur begins in the light of confirmation of the delusion of infidelity.

After some time, the delirium crystallizes, a coherent structure of delirium is formed, at this time any attempts to prove the opposite to the patient are perceived aggressively. Usually cases of violence occur at this stage. And if it is possible to survive this stage without losses (for example, by placing the patient in a medical institution where he will receive help), then you can see the delirium fading, when criticism of delusional statements, evidence of the partner's innocence begins to be perceived.

Residual delirium persists for a long time after treatment. It is usually present in cases of paranoid disorders with hallucinations, recovery from delirium and from the twilight state in epilepsy.

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Forms

Manic delusion of jealousy is a variation of manic psychosis, when the overvalued idea is the betrayal of a sexual partner. In this case, the patient is overexcited, hyperactive, easily excitable, and prone to aggressive paroxysms. An individual obsessed with mania of jealousy does not accept any arguments in defense of the accused, he is firmly convinced of adultery, and the excitability, aggressiveness, and tendency to active actions accompanying this type of pathology make the patient unpredictable and dangerous.

Depressive delusions of jealousy are often ignored because the person curtails communication, avoids sympathetic questions, and his close circle tries not to pester him, hoping that the depression will recede. And they start to sound the alarm only when the patient stops eating or showing up for work.

Hypertrophied jealousy is expressed in a superlative degree of demonstration of ordinary jealousy. For example, the routine smile of a salesperson or bartender can unexpectedly cause an outburst of delusional jealousy.

Paranoid delusion of jealousy is the most complex, persistent and insidious form of delusion. It differs from manic delusion of jealousy by its unyielding jealousy of everything and everyone, which is not related to the circumstances. Paranoid delusion of jealousy is usually complex in content, with a clear, logical and complete structure of circumstances and conclusions, absolutely unreal and existing exclusively in the mind of the patient.

Fear of divorce also provokes delusional jealousy. Women are more prone to this type. Panic fear of divorce makes one look everywhere for the homewrecker who threatens to destroy her family nest. The result is constant searches, inspections, investigations and scandals.

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Alcoholic delirium of jealousy

Delusional disorder, accompanied by pathological jealousy towards a sexual partner, developing on the basis of alcoholism, is quite common, since alcohol is the most accessible psychoactive substance.

Observations show that this mental pathology is quite common for stages I-III of alcoholism. The causes of alcoholic delusions of jealousy are considered to be: organic brain damage due to regular drunkenness, paranoid or epileptoid characteristics of personality behavior, personality degradation, sexual dysfunction against the background of alcoholism, manifestations of jealousy before the onset of alcohol dependence.

The acute form of alcoholic delusional jealousy develops during the hangover syndrome or approximately on the third day of recovery from binge drinking. Under the influence of visual and/or auditory hallucinations, the patient accuses the partner of infidelity, provides "evidence" of betrayal.

The chronic form usually occurs at the stage of systemic alcohol intoxication. Pathological jealousy acquires more dangerous features - checks, stalking, searches, aggressive behavior, beatings begin.

Signs to pay attention to: the person constantly has a far-fetched idea of infidelity, he is engaged in detective work in order to prove this betrayal, looks for a subtext in every word, tries to isolate the partner from communication with others, shows aggression and violence. If such symptoms are present, it is necessary to seek medical help from a psychiatrist and narcologist. The dynamics of alcoholic delirium of jealousy are described above.

Often the disease remains unrecognized for a long time, since aggression in alcoholism is not uncommon, and some patients do not voice their suspicions until the delirium has completely crystallized. In this case, there is a real danger primarily for the patient's wife, "non-native" children, aggression towards a rival is observed much less often. The consequences and complications of alcoholic delirium of jealousy can be sad.

The structure of alcoholic delusions of jealousy, according to observations, is always paranoid. The plot of alcoholic delusions is more plausible than, for example, schizophrenic. In alcoholism, the rival in all cases was a specific person. Accusations of incest, delusions of jealousy, combined with delusions of persecution, for example, the unfaithful spouse was accused of trying to poison the patient, were not uncommon.

Alcoholic delirium of jealousy is accompanied by rapid degradation of personality. Affective disorders are more often dysphoric in nature, rather than anxious-depressive. The patient's behavior is aggressive and fully corresponds to the plot of the delirium.

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Diagnostics delusions of jealousy

People with alcoholic delusions of jealousy are socially dangerous. Considering that they are predisposed to conceal their pathology, especially from medical professionals, when alcoholic delusions of jealousy are suspected, a test with ethyl alcohol is often performed. A 20% solution of ethyl alcohol is administered intravenously to the patient. A quarter of an hour later, alcohol intoxication occurs with an exacerbation of delusional ideas, during which the patient confides in the doctor about his suspicions and lays out evidence of his spouse's infidelity.

Diagnosis of delusional jealousy requires a multifaceted approach. A detailed psychiatric anamnesis is collected, and it is desirable to conduct repeated joint and individual interviews of both partners.

A complete psychiatric history should include information about the family, the quality of the relationship, and the presence of mental illness. During the interview, it is necessary to show interest in pathological manifestations of jealousy, the use of psychoactive substances, and the use of violence both in the past and in the present. Both partners should be asked about clashes, scandals, intimidation, and the criminal actions of jealous people. If the couple has children, their safety must be taken care of.

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Differential diagnosis

To assess the patient's condition and the degree of danger to others, based on the interview results, differential diagnostics are carried out, determining the symptoms of delirium, allowing one to distinguish delusional ideas of jealousy from obsessive or overvalued ones.

When assessing the possibility of suicide, it is also necessary to interview both partners.

When conducting diagnostics, it is necessary to take into account that the mental disorder causing delusional jealousy arose and manifested itself earlier, its symptoms appear simultaneously with jealousy, the pathological processes of both disorders are interconnected, delusional jealousy is not based on real facts.

Treatment delusions of jealousy

After diagnostics and diagnosis, it is necessary to familiarize both partners with the consequences and complications of such a mental state. Usually, the patient must agree to treatment, the exception being cases that pose a threat to the life of his partner.

Preventive measures are taken to protect the potential victim and create safe conditions for children. If the risk is high, the patient with symptoms of delusional jealousy should be urgently hospitalized.

Treatment of delusional jealousy is carried out in two directions: therapy of mental illnesses and reduction of the risk of violence.

Treatment includes drug therapy, psychosocial measures and hospitalization (including forced hospitalization). Drug therapy is carried out using neuroleptics and antidepressants.

Delusional jealousy disorders and schizophrenic delusions of infidelity are treated with neuroleptics. In case of symptoms of obsessive jealousy with or without a depressive component, antidepressants give a good effect.

Psychosocial interventions include drug addiction treatment, cognitive behavioral therapy, family relationship therapy, psychoanalytic assistance, and measures to ensure the safety of the potential victim and children.

Cognitive behavioral therapy is effective in cases of obsession, psychoanalytic psychotherapy is also used for this symptom, and it is also used to treat delusional jealousy in people with borderline and paranoid disorder.

The greatest effect from treatment and preventive measures is achieved with early recognition of the symptoms of delusional jealousy.

In milder cases, with pathological jealousy due to fear of divorce or caused by a personality disorder, psychological or psychotherapeutic help may be sufficient. If delusional jealousy is a symptom of a mental illness, then psychiatric and drug treatment are needed.

Since people suffering from delusional jealousy are usually sure that there is no need for treatment, since they are healthy, they try to ignore the doctor’s orders, and accordingly the therapeutic effect is small.

If delusional jealousy is associated with obvious suffering, risk for both the jealous person and his environment, and also if outpatient therapy is ineffective, inpatient treatment is necessary. However, a common pattern is observed - in the hospital, the patient quickly shows a positive therapeutic effect, and in the family circle the disease recurs.

If the treatment is ineffective, for safety reasons it is recommended that the couple live separately.

Prevention

Jealousy as an emotional manifestation in accordance with the situation does not pose a danger.

If jealousy is accompanied by a mental disorder in a person, he splashes out emotions aggressively, then there is a risk of injury, murder or suicide.

If the situation in the family is escalating and not controlled, and delusional manifestations of jealousy are repeated daily, it is necessary to consult a psychologist (psychotherapist).

Preventive measures recommended by psychologists: do not ask about your partner’s past hobbies, do not investigate, do not pay attention to provocative behavior, do not provoke outbursts of jealousy.

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Forecast

The prognosis of delusional jealousy is influenced by the underlying disease, the presence of concomitant mental disorders, and resistance to treatment. Individuals with psychotic disorders are less responsive to treatment.

It is quite possible that delusional jealousy will return some time after treatment, so it is recommended to remain under the supervision of a doctor for a long time. In psychiatric practice, there have been relapses of murders based on pathological jealousy, committed after many years of apparent well-being.

Delusional jealousy is a symptom observed in various mental disorders, the manifestations of which are delusional, obsessive, overvalued ideas or their combinations. Its manifestations, the severity of the disease, identified on the basis of the medical history and diagnosis of mental disorder, will indicate the underlying pathology and accompanying conditions, and will allow prescribing appropriate treatment. A significant circumstance aggravating the course of delusional jealousy is alcoholism, drug addiction, and toxicomania.

Given the potential for dramatic consequences, delusional jealousy is a condition that requires active medical intervention.

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